Orthopedic Coding Alert

E codes can get your claim paid faster.

Although you have no national standards to follow regarding workers compensation claim coding, you can cut down on the headaches getting these claims paid can cause if you follow some universal diagnosis and evaluation coding guidelines.

Myth #1: You Should Use 99455-99456 for E/M Visits

Reality: If your orthopedic surgeon sees a workers compensation (WC) patient for an independent medical evaluation (IME) at the request of the patients employer or insurer, you should familiarize yourself with the WC E/M codes. To describe work-related or medical disability evaluations, CPT contains:

" 99455 -- Work related or medical disability examination by the treating physician that includes: completion of a medical history commensurate with the patients condition; performance of an examination commensurate with the patients condition; formulation of a diagnosis, assessment of capabilities and stability, and calculation of impairment; development of future medical treatment plan; and completion of necessary documentation/certificates and report

" 99456 -- Work related or medical disability examination by other than the treating physician &

You should report 99455 and 99456 only for special medical evaluations that include extensive tests for disability status, says Mary Baierl, RHIT, CPC, CCA, CMT, HIM coder at BayCare Health Systems LLC in Green Bay, Wis. These codes are much more involved than just the routine office visit history-taking, physical exam, and medical decision making. They include very individualized, specialized evaluation and testing to determine the level of the patients disability. In other words, you should not use 99455 and 99456 for standard E/M services.

Dont miss: If your orthopedist performs an E/M service in addition to a WC evaluation, however, you can report 99201-99215, (Office or other outpatient visit for the evaluation and management ...) in addition to 99455/99456, says Angelica Stephens, CCS-P, CPC, CPC-H, coding and billing coordinator for NMOSC in Albuquerque, N.M.

Myth #2: WC Patient? Always Report WC Codes

Reality: Dont automatically report the WC codes whenever a workers compensation patient presents to your practice.

You should use these codes only if a patients employer or insurance company requires a physical for employment or medical-disability purposes. If your surgeon subsequently takes over care of the patients work-related condition, you should then revert to the standard E/M codes (99201-99215).

The introductory language describing the workerscomp codes specifically indicates that when using these codes, no active management of the problem(s) is undertaken during the encounter.

Myth #3: Data About the Accident Is Unnecessary Reality:

Most insurers require the date of injury,workers compensation claim number, employer at the time of injury, adjustor and case managers name and phone number, and alternative private insurance information.

Keep this information in the patients file, and submit it to the carrier when necessary.

Good idea: You can make your job easier if you ensure that your practices intake form includes a box that asks, Are you here for a work-related accident? That way, the nurse will chart the pertinent work-related details, which youll need later when you file your claim.

Myth #4: You Dont Need to Preauthorize WC Claims

Reality: If at all possible, you should obtain authorization from the workers compensation carrier to treat the patient before you provide the initial visit.

Even if you collect the appropriate information and preauthorize the visit, you may still run into roadblocks when you submit your claim, because WC claims are not regulated by any one source.

Each state has its own WC regulations, and not every state uses current-year CPT codes, says Marvel Hammer, CPC, CCS-P, PCS, ACS-PM, CHCO, consultant with MJH Consulting in Denver.

Each state has its own little idiosyncrasies, Hammer says, so you should check your state workers compensation carriers Web site before you code.

Myth #5: You Dont Need E Codes

Reality: You should always use an E code from the ICD-9 manual to describe the mechanism of injury and place of occurrence (E800-E999, Supplementary classification of external causes of injury and poisoning). Although you cannot report the E code as your primary diagnosis, you can list it after the main diagnoses so the insurer gets an idea of how the accident happened.

In addition, some patients may have more than one WC claim open and in the system, so the E code can help the carrier differentiate between the claims and get them paid faster, Hammer says.

For example, suppose a patient fell from a ladder and complained of wrist pain. Your surgeon does not find a fracture, but he splints the wrist. You should report 842.xx (Sprains and strains of wrist and hand ...) followed by E881.0 (Fall from ladder).

Myth #6: File Your Claim in State Accident Occurred

Suppose a patient who lives in Arkansas falls off a ladder in Texas and comes to your practice in Arkansas for treatment. Should you file in Texas or Arkansas?

Reality: The answer depends on where the patients employer filed the claim. If the employer is in Louisiana and filed the claim there, you should deal with the Louisiana WC carrier --not with Texas or Arkansas.

You can check out each states workers compensation agency pages by visiting the Web site www.comp.state.nc.us/ncic/pages/all50.htm.